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Applications Will Be'Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: r; APPLICATION <br /> (For Non-Transierable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address :3 y tri City/Town <br /> Owner's Name4. r Phone <br /> Address ~ City <br /> Contractor's Name License#3_33 7! Business Phone <br /> Contractor's Address &4,4' zi— Emergency Phone r.:1 <br /> Is Certificate of Workman's Compensation Insurance on File Ith SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIO,,N,❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ y <br /> DISTANCE TO NEAREST: Septic Tank : Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL t <br /> I <br /> ❑ INTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 3 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> © DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout I <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: j <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P <br /> i PUMP REPLACEMENT: ❑ State Work Don (� <br /> PUMP REPAIR: ❑ State;Work Done i <br /> DESTRUCTION OF WELL: Well Diameter' Approxi mate Depth <br /> Describe Materia!and Procedure <br /> I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health'District! <br /> Homeowner or licensed agent's Signature certifies the following:"!certify that in the performancelof the work for which this permit <br /> is issued, I'shall-not employ any person in such manner as to become subject,to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: ; <br /> I g 9 g g:"I certify that in the performance of the work forwhictl this <br /> permit,is issued, I shall employ persons subject to workman's compensation laws of Californiaj" <br /> i r <br /> I wi! xjll for a Gro t Inspection prior to grouting and a final inspection. <br /> Signed X Title: OiAwn_._ rt Date: <br /> (Draw Plot Plan on Reverse Side) J <br /> OR TMENT USE ONLY <br /> PHASE <br /> Application Accepted <br /> Date- <br /> Additional Comments: ' f` <br /> Phase 11 Grou Inspection _ �_- ; ¢, Phase'III:_ iriai- ection <br /> Inspection By Date Inspection 13y ate Sz1 00 , <br /> i —Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE, $ REMIT <br /> BASE EXPLANATION PATE, DATE REMITTED AMOUNT DUE CHECKED .` <br /> AMOUNT <br /> FEE q S <br /> LESS <br /> PRORATION a <br /> PLUS <br /> i PENALTY <br /> OTHER <br /> OTHER <br /> 15 <br /> Received by Date t Receipt No. Permit No. - ia&uanc;b Date Mailed - Deli red <br /> - APPLICANT—RETURN ALL COPIES TO:—ENVIRONMENTAL HEALTH PERMITISERVICE$- 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 ._ <br />